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Thursday, September 17, 2015

Coverage of left subclavian artery during TEVAR may require a more liberal strategy to prevent endoleaks

A recent study from researchers at the University of Virginia was done to report the outcomes of coverage of the LSCA during TEVAR. A retrospective review was performed and included 285 patients with 98 (34%) having coverage of the LSCA. Of the covered patients, the LSCA was revascularized at time of initial TEVAR in 44/98 (45%). Of the remaining 54 patients, 10 (19%) required subsequent revascularization for claudication. LSCA embolization was performed in 33/98 patients at time of LSCA coverage. However, 8 of remaining 65 patients required subsequent embolization for persistent endoleak. There was a statistically significant increased CVA rate with coverage of the LSCA when compared with uncovered (11% vs 3%). While the authors concluded that a selective LSCA revascularization and embolization strategy is well tolerated, a more liberal strategy may be required to decrease rates of delayed revascularization and embolization procedures.

Comment:

The study used a previously established selective revascularization strategy based on a set of indications identifying patients at higher risk of CVA and spinal cord ischemia. While this selective LSCA revascularization and embolization strategy is well tolerated with acceptable rates of CVA and spinal cord ischemia, the increased rates of delayed revascularization secondary to arm claudication symptoms and embolization for endoleak suggest that the criteria for and approach to LSCA coverage should be refined. Going forward, given the relatively small sample size of the current study and the heterogenous patient population, it is difficult to make more definitive treatment recommendations regarding revascularization and embolization strategy on the basis of the available data. However, given that many endoleaks were not angiographically evident at time of initial coverage, one may advocate for a more aggressive embolization strategy to prevent the need for future endoleak repair.